Provider Demographics
NPI:1932192549
Name:LISLE, MARGARET ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARGARET
Middle Name:ANN
Last Name:LISLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1044
Mailing Address - Country:US
Mailing Address - Phone:812-346-8500
Mailing Address - Fax:812-352-8308
Practice Address - Street 1:747 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1044
Practice Address - Country:US
Practice Address - Phone:812-346-8500
Practice Address - Fax:812-352-8308
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003048A152W00000X
KY1414DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200345210Medicaid
IN200335310AMedicaid
IN4331560001Medicare NSC
INU85567Medicare UPIN
IN182120BMedicare ID - Type UnspecifiedINDIVIDUAL NUMBER
IN200345210Medicaid